INFECTIOUS

MONONUCLEOSIS
Epstein-Barr Virus (EBV)

American workers
Paul first described the established the
presence of sheep cell relationship of EBV to
agglutinins in the sera of Burkitt describe a tumor in several cancers e.g.
patients with IM African children Burkitt's lymphoma

1966–
1932 1937 1958 1964 1984
1968

Davidsohn demonstrated Dr. Anthony Epstein and The entire genome of one
that the heterophil Yvone Barr isolated the EBV strain was
antibodies in patients with virus from Burkitt’s sequenced
IM are absorbed by beef lymphoma cells (thus the
erythrocytes, in contrast to name EBV), Drs. Werner
heterophil antibodies and Gertrude Henle
present in other disorders. established the
relationship of EBV to
several cancers (e.g.,
Burkitt lymphoma)
 • The most intensively studied human cancer virus
• Causes an acute, benign, self-limiting lymphoproliferative
disease called infectious mononucleosis
• Also causes Burkitt's lymphoma (a malignant tumor of the
lymphoid tissue common among African children),
nasopharyngeal carcinoma, and neoplasms of the thymus,
parotid gland and supraglottic larynx
• An important factor in the development of nasopharyngeal
carcinoma, an epithelial cancer
• 95% of the world’s population is exposed to the virus (most
EBV ubiquitous virus known to humans)
• A human herpes virus that infects B lymphocytes
• Atypical lymphocytes found in the peripheral blood are
large, effective CD8+ cytotoxic T cells responding
against EBV infected circulating B lymphocytes
• Replication:
• Attaches to cells by binding to the C3d receptor (CD21)
• Binding is mediated by the EBV glycoprotein
Epstein-Barr
Virus
 Antigens
• EBNA – Epstein-Barr Viral Nuclear
Antigen
• LYDMA – Lymphocyte Detected
Membrane Antigen
• MA – Membrane Antigen
• VCA – Viral capsid Antigen
• EA – Early Antigen
EBV
• Epidemiology (already on slide 4)
• The most ubiquitous virus known to
man
• Approximate 90% of adults
demonstrate antibodies to the virus
Mode of Transmission

• EBV in infants: asymptomatic infection

• Seroconversion without any signifcant clinical signs or symptoms of disease
• Close contact with infectious oral pharyngeal secretions
• Blood transfusion (infectious mononucleosis postperfusion syndrome)
• Transplacental routes
• By mosquito
• Minor problem for immunocompetent person but can become a major concern for
immunocompromised persons
• Reactivation of latent EBV infection: EBV-associated fatigue syndrome
• Infectious mononucleosis: 45/100,000 in adolescents
• Immunosuppressed patients: EBV infection ranges from 35% to 47%
 • Infectious Mononucleosis – an acute infectious
disease of the mononuclear phagocyte system
• Chronic EBV – chronic tiredness, low grade fever,
headaches & sore throats
• EBV Induced Lymphoproliferative disease –
acquired by individuals lacking T cell immunity
Clinical • Burkitt’s Lymphoma – poorly differentiated
monoclonal B cell lymphoma of the jaw & face of
Manifestation mostly African children
• Nasopharyngeal carcinoma – tumor endemic in the
Orient
• Hairy Oral Leukoplakia – causes lesions in the
mouth, opportunistic presentation of AIDS
Oral Hairy
Leukoplakia
 • a.k.a. “Kissing’s Disease”, “Glandular
Fever”
• Typically asymptomatic in young adults
• Incubation period: 10-50 days, if fully
developed, lasts for 1 to 4 weeks
• Clinical Symptoms
• Fever
Infectious • Fatigue
• Chilling
Mononucleosis • Hepatomegaly
• Sore throat
• Splenomegaly
• Headache
• Enlargement of lymph nodes
• Malaise
 Hematologic findings
1. Leukocytosis (10 to 20 x 109/L)
2. Leukopenia (10%)
3. 60-90% typical lymphocytes, 5-30%
Diagnostics variant lymphocytes
Atypical lymphocytes
• CD8+ T
cells reacting
to infected B
cells
 Heterophile antibodies
– 56 or greater = IM
– IgM - present during acute phase
• reacts with horse, ox(beef) and sheep erythrocytes
• adsorbed by beef erythrocytes
• not adsorbed by guinea pig kidney cells
• does not react with EBV-specific antigens
• Paul and Bunnell first associated IM with sheep cell
agglutination and develop a test for IM heterophile
Diagnostics • Davidsohn modified the original Paul-Bunnell by
introducing a differential adsorption aspect to remove
cross-reacting Forssman and serum sickness heterophile
antibodies
• Some individuals are heterophile negative, in this case, an
EBV serologic panel may be requested
• Availability of rapid agglutination slide tests
 Epstein-Barr Virus Serology
• 10% to 20% of individuals with acute IM do not produce
heterophile antibody
• 50% of children younger than 4 years with IM are
heterophile negative
• Infection with EBV: viral capsid antigen (VCA), early
Diagnostics antigen (EA), and nuclear antigen (NA), with
corresponding antibody responses,
• Patients with nasopharyngeal carcinoma: with elevated
titers of IgA antibodies to EBV replicative antigens,
including VCA (these antibodie serve as a prognostic
indicator of remission and relapse)
 Viral capsid antigen (VCA)
• Produced by infected B cells and can
be found in the cytoplasm
• Anti-VCA IgM - detectable early in
Diagnostics the course of infection.
• Anti-VCA IgG - usually detectable
within 4-7 days
 Early antigen (EA)
• Complex of early antigen-diffuse (EA-D) and early
antigen-restricted (EA-R)
• EA-D of the IgG type: highly indicative of acute
infection (EA-D disappears in about 3 months)
Diagnostics • Anti–EA-R IgG: not usually found in young adults
during the acute phase
• Both nti–EA-D and anti– EA-R IgG are not consistent
indicators of the disease stage
 Epstein-Barr Nuclear Antigen (EBNA)
• Found in the nucleus of all EBV-
infected cells
• Anti-EBNA IgG - appears during
convalescent phase
• EBNA antibodies always present in
sera containing IgG antibodies to
VCA of EBV
• Test results of antibodies to EBNA
Diagnostics should be evaluated in relation to
patient symptoms, clinical history, and
antibody response patterns to VCA
and EA to establish a diagnosis
• In immunocompromised patients,
serologic tests are of limited value and
determination of EBV viral load by
PCR is preferred
 • Forssman Heterophile Abs
• Abs of low titer in normal population
• No clinical significance
• Serum Sickness Heterophil Abs
• Seen in more senior population
Heterophile • Infectious Mononucleosis Heterophil Abs
Antibodies • First described by Paul Bunnell
• a.k.a. antisheep agglutinins
• NOT specific for IM and can be present in other
disorders
 Screening Test (Presumptive Test)
• Principle: Hemagglutination
• Patient serum (inactivated/diluted) + sheep erythrocytes
• Indicates the presence or absence of heterophile antibodies
• CANNOT differentiate the three heterophile Abs

1:7 1:14 1:28 1:56 1:112 1:224

• False (+) - hepatitis, Hodgkin disease
• Improper inactivation – hemolysis
• Limitation: The test is only indicative of the presence or absence of heterophile antibodies

Paul-Bunnell Test
Davidsohn Differential Test
• Confirmatory Test (Verification Test)
• Identifies the heterophile antibodies that agglutinate sheep erythrocytes
• Highly specific for IM
• Based on fact that sheep and beef(ox) erythrocytes (BEA) bear some common
antigen not present on guinea pig kidney cells (GPK)
• Tissues rich in Forssman antigen (GPK) absorb Forssman antibodies but do
NOT affect the heterophil antibodies in IM.
• Performed only if the preliminary Paul-Bunnell test is positive in a titer of 56 or
greater
• Limitation: the test is time-consuming
 Procedure
Davidsohn 1. Adsorb patient serum with GPK cells.
Differential • Only Forssman and serum sickness heterophile antibodies
will be adsorbed. IM heterophile antibodies will remain in the
Test serum.
2. Centrifuge
3. Dilute supernatant and react with sheep erythrocytes
• Only IM heterophile antibodies will react.
• If cells are agglutinated, IM antibodies are present
• If cells are NOT agglutinated, IM antibodies are absent,
Forsmann and serum sickness heterophile antibodies are
present.
 GPK- FORSSMAN and SERUM
BEA- SERUM and IM

GPK BEA
Forssman + -
Serum Sickness + +
IM - +
 • The spot test for IM is based on the principle that
horse erythrocytes are more sensitive than sheep
erythrocytes in testing for IM.
• Uses 20% horse rbc instead of sRBC
• Horse rbcs exhibit both antigens directed against both
Forssman and IM antibodies. Differential adsorption
using GPK and BEA cells are necessary.
• A positive test for IM shows agglutination of horse
Monospot/MonoSlide erythrocytes by serum absorbed with guinea pig
Test kidney, but NOT by serum absorbed with beef
erythrocyte stroma
• (+) dark clumps against a blue-green background
• Limitation: some segments of the population do not
produce detectable heterophile antibody
• Others: Wampole Laboratories Colorcard Mono and
Mono-plus.
 PRIMARY TARGET SITE OF
TYPE SYNONYM PATHOPHYSIOLOGY
CELL LATENCY
Oral and/or genital herpes
HHV- Herpes simplex virus-
Mucoepithelial Neuron (predominantly orofacial), as well as
1 1 (HSV-1)
other herpes simplex infections
Oral and/or genital herpes
HHV- Herpes simplex virus-
Mucoepithelial Neuron (predominantly genital), as well as
2 2 (HSV-2)
other herpes simplex infections
HHV- Varicella zoster virus
Mucoepithelial Neuron Chickenpox and shingles
3 (VZV)
Infectious mononucleosis, Burkitt's
lymphoma, CNS lymphoma in AIDS
patients,
HHV- Epstein-Barr virus B cells and
B cell post-transplant lymphoproliferative
4 (EBV) epithelial cells
syndrome (PTLD), nasopharyngeal
carcinoma, HIV-associated hairy
leukoplakia
 PRIMARY TARGET SITE OF
TYPE SYNONYM PATHOPHYSIOLOGY
CELL LATENCY

Monocyte, Monocyte,
Infectious mononucleosis-like
HHV-5 Cytomegalovirus (CMV) lymphocyte, and lymphocyte,
syndrome, retinitis, etc.
epithelial cells and ?

Sixth disease (roseola

HHV-6 Roseolavirus T cells T cells infantum or exanthem
subitum)

HHV-7 T cells T cells

Kaposi's sarcoma- Kaposi's sarcoma, primary

associated herpesvirus Lymphocyte and effusion lymphoma, some
HHV-8 B cell
other cells types of multicentric
(KSHV) Castleman's disease
The end